Pradhan Mantri Jan Arogya Yojana (PMJAY): Affordable Healthcare for India's Low-Income Families

Pradhan Mantri Jan Arogya Yojana (PMJAY): Affordable Healthcare for India's Low-Income Families

Rising medical costs pose a significant challenge, especially for low-income families in India. Recognizing this gap, the Pradhan Mantri Jan Arogya Yojana (PMJAY), also known as Ayushman Bharat, was launched in September 2018 to bridge the affordability gap and provide quality healthcare access to these populations.

PMJAY is the world's largest government-funded health insurance scheme, offering a covetable Rs. 5 lakh (US$6,700 approx.) per family per year. This scheme targets over 50 crore (500 million) beneficiaries, encompassing nearly 10.74 crore poor and vulnerable families across India.

Key Features

• Financial Coverage: PMJAY offers cashless and comprehensive coverage of Rs. 5 lakh on a family floater basis. This implies that the entire family can avail benefits up to this limit.
• Hospitalization Coverage: The scheme covers secondary and tertiary care hospitalization expenses across a network of empanelled hospitals in India, both public and private.
• Pre-Existing Illness Coverage: Unlike many private health insurance plans, PMJAY covers pre-existing illnesses from the very beginning of the policy.
• Free for Beneficiaries: This government-funded scheme eliminates any financial burden on beneficiaries. The Central and State Governments share the premium cost in a 60:40 ratio.

Who is Eligible?

PMJAY beneficiaries are identified based on a socio-economic and occupational criteria analysis conducted in 2011 (SECC 2011). Here's a glimpse into the eligibility categories:

Rural Areas:

• Families covered under the earlier Rashtriya Swasthya Bima Yojana (RSBY) scheme
• Individuals belonging to Scheduled Castes (SC) and Scheduled Tribes (ST)
• Poor families without a male member aged 16-59 years
• Beggar families
• Families with no healthy adult member between 16-59 years and a disabled member
• Landless families or those relying on casual labor
• Legally released bonded workers
• Manual scavenger families
• Primitive tribal communities
• People living in one-room makeshift houses

Urban Areas:

• Rag pickers, washermen, chowkidars (security guards)
• Domestic workers, repair workers, tailors
• Sanitation workers, gardeners, cobblers, hawkers, street vendors
• Transport workers
• Shopkeepers, peons, assistants, waiters (working in small establishments)

No Age or Family Size Restrictions:

PMJAY imposes no limitations on the entry age, the number of family members covered, or the exit age for eligible beneficiaries.

Who is Not Eligible for PMJAY?

Individuals falling under the following categories are not eligible for PMJAY benefits:

• Owners of any type of vehicle or mechanized farming equipment
• Government employees
• Individuals with a Kisan card exceeding Rs. 50,000 limit
• Those earning a monthly income of Rs. 10,000 or more
• People working in non-agricultural government-managed enterprises
• Owners of refrigerators, landlines, or 5+ acres of agricultural land
• Residents of well-built houses

What Medical Expenses Does PMJAY Cover?

PMJAY offers a broad spectrum of medical expense coverage, including:

• Pre-hospitalization expenses for 3 days
• Post-hospitalization expenses for 15 days
• In-hospital consultations, examinations, and treatments
• ICU and non-ICU care
• Medical implantation services
• Diagnostic and laboratory tests
• Hospital stay and room rent
• Specified medical procedures
• COVID-19 treatments

The scheme also provides pre-defined packages for various medical conditions.

What is Not Covered Under PMJAY?

While PMJAY offers extensive coverage, some exclusions exist:

• Cosmetic surgeries
• Drug rehabilitation costs
• Organ transplant surgeries
• Outpatient Department (OPD) expenses
• Fertility treatments
• Individual diagnostic tests for general health checkups

Benefits of PMJAY

PMJAY has been a game-changer for low-income families, granting them access to quality healthcare that was previously out of reach. The scheme's cashless treatment feature eliminates upfront payments at empanelled hospitals, significantly reducing financial stress during medical emergencies.

Enrolling for PMJAY

The government has proactively enrolled identified beneficiaries. These families have received health cards that enable cashless treatment at empanelled hospitals. To verify your eligibility, visit a Common Service Centre (CSC), call the helpline numbers 14555 or 1800